Reseller Application

Legal Business Name:*

Doing Business As:

Phone:*

Website:

Billing Address:*

Billing City:*

Billing State/Province:

Billing Zip:

Billing Country:*

Shipping Address:

Shipping City:

Shipping State/Province:

Shipping Zip:

Shipping Country:

Buyer Contact First:

Buyer Contact Last:

Buyer Title

Buyer Telephone:

Buyer Email:

Accounts Payable Contact First Name:

Accounts Payable Contact Last Name:

Accounts Payable Contact Telephone:

Accounts Payable Contact Fax:

Accounts Payable Contact Email:

Years in Business:

Federal Tax ID:

Resale License:

VAT/GST:

If Other Specialty Market:

Bank 1 Name:*

Bank 1 Contact:*

Bank 1 Telephone:*

Bank 1 Fax:*

Bank 1 Account Number:*

Bank 1 Name on Account:*

How long has this account been established? (Bank 1)*

Bank 2 Name:

Bank 2 Contact:

Bank 2 Telephone:

Bank 2 Fax:

Bank 2 Account Number:

Bank 2 Name on Account:

How long has this account been established? (Bank 2)

Supplier 1 Name:

Supplier 1 Name:

Supplier 1 Telephone:

Supplier 1 Email:

Supplier 1 Account Number:

Supplier 1 Credit Limit:

How long has this account been established? (Supplier 1)

Supplier 2 Name:

Supplier 2 Name:

Supplier 2 Telephone:

Supplier 2 Email:

Supplier 2 Account Number:

Supplier 2 Credit Limit:

How long has this account been established? (Supplier 2)

Supplier 3 Name:

Supplier 3 Name:

Supplier 3 Telephone:

Supplier 3 Email:

Supplier 3 Account Number:

Supplier 3 Credit Limit:

How long has this account been established? (Supplier 3)

First Name:*

Last Name:*

Title:*

Email:*